Care Coordination Cohort

About the Care Coordination Cohort

The group of North Sound partners engaged in the Care Coordination Cohort are at the front end of helping community members navigate a complex, disconnected, and disorganized system of care and services. This cohort is committed to finding ways to meet the needs of those most challenged by the current systems – ranging from emergency responders, health systems, community clinics, social service agencies and public health. 

The Care Coordination cohort initially identified three focus areas, and is finding that there is a lot of overlap among them:

  • Care Coordination HUB, trying to grow the regional North Sound Community HUB by sharing an information platform, advancing workforce strategies in support of community health workers, and acting as a network broker to bring payments to community care coordinators.
  • Cross Sector Care Coordination, an effort to address needs of community members who intersect with multiple systems and sectors – those who are familiar faces to emergency departments, courts, housing and advocacy agencies because they have clinical, social, legal, and financial needs. 
  • Mobile Integrated Health, accelerated by COVID-19, the focus is on care coordination that occurs outside of clinic or office settings. Examples include Fire and EMS units who check on community members who are often transported to the emergency department but not admitted, and Federally Qualified Health Centers (FQHCs) and Community Action Agencies working at homeless shelters trying to manage complex medical and behavioral health issues. Even though the ambulance ride to an emergency department is commonly used, complex patients often are put back into the community; if their needs can be met in the community this would improve quality of life and save resources.

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